Identifying suicide crisis syndrome with Dr. Igor Galynker (Part 2)

Show Notes

Last week, Igor Galynker, MD, PhD, spoke with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about how to identify suicide crisis syndrome. This week, he explores the kinds of "gut feelings" that clinicians can access to help them identify when a patient might have the syndrome.

Dr. Galynker has been a guest on the Psychcast twice before, once to discuss the impact of suicide on physicians and a second time to talk about his research on the arguments for adding a suicide-specific diagnosis to the DSM-5. He is associate chairman for research in the department of psychiatry at Mount Sinai Beth Israel in New York. In addition, Dr. Galynker is founder and director of the Richard and Cynthia Zirinsky Center for Bipolar Disorder, and professor of psychiatry at the Icahn School of Medicine, both at Mount Sinai.

Later, Renee Kohanski, MD, discusses the ability of psychiatrists to help patients realize that they can choose what matters in their lives. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

Show Notes by Jacqueline Posada, MD, who is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

The "gut feelings" -- emotional reactions to the patient in suicide risk assessment -- also will elicit behaviors from a clinician.

Behavioral signs of the four emotions are pertinent for clinicians who are burned out or may have limited emotional awareness. Examples include:

• Anxious overinvolvement manifested as going above and beyond for a patient; doing things that are out of character, such as answering phone calls/texts on the weekend; reluctance to set boundaries.
• Dislike and distancing: The patient in suicide crisis syndrome will be the last one the clinician sees on the inpatient unit or the one he/she postpones or forgets to see; the clinician experiences dread tied to the prospect of seeing a patient all day, shortens sessions, or does not answer phone calls.

How to combine emotional response and the suicide crisis syndrome.

• New research from Dr. Galynker and colleagues suggests that the predictive validity for suicide risk doubles if the patient meets criteria for suicide crisis syndrome and the clinician has an emotional response as described above.
• The emotional response is elicited not just from the suicide crisis syndrome but also from the suicidal narrative.
• The narrative of a suicidal person describes an intolerable present with no future. This type of aberrant narrative triggers an emotional response in the clinician.
• One could argue the electronic medical record makes it difficult to understand the patient's narrative, which can impede the clinician's ability to have an emotional response to the patient's suffering.

Why has psychiatry not focused on suicide over other mental health diagnoses?

• As a transdiagnostic phenomenon, one could argue that suicide must be a primary focus of assessment and treatment by psychiatrists.
• Suicide elicits a variety of cultural responses, ranging from shame, disgust, and a sense of weakness to empathy for the pain and suffering of a suicidal person.
• It is difficult to connect with someone who is suffering from a desire to die, but this might be what the patient wants.
• Clinical excellence is the ability to connect with a variety of patients in different settings, and it's about demonstrating how one cares.

References

Olfson M et al. Short-term suicide risk after psychiatric hospital discharge. JAMA Psychiatry. 2016 Nov 1;73(11):1119-26.

Galynker I et al. Prediction of suicidal behavior in high-risk psychiatric patients using an assessment of acute suicidal state: The suicide crisis inventory. Depress Anxiety. 2017 Feb;34(2):147-58.

Cohen LJ et al. The suicide crisis syndrome mediates the relationship between long-term risk factors and lifetime suicidal phenomena. Suicide Life Threat Behav. 2018 Oct;48(5):613-23.

Suicide rising across U.S. Centers for Disease Control and Prevention. Vital Signs. 2018 Jun.

Oquendo MA and E Baca-Garcia. Suicidal behavior disorder as a diagnostic entity in the DSM-5 classification system: Advantages outweigh limitations. World Psychiatry. 2014 Jun;13(2):128-30.

Fawcett J. "Diagnosis, traits, states and comorbidity in suicide" in The Neurobiological Basis of Suicide. Boca Raton, Fla.: Taylor & Francis, 2012.

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